37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 490930 |
Time | |
Date | 200011 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 msl bound upper : 21000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zny.artcc |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 140 flight time total : 3500 flight time type : 1583 |
ASRS Report | 490930 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 5000 |
ASRS Report | 490919 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : pack temp other flight crewa other flight crewb |
Resolutory Action | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Crew operated left air conditioning pack when the pack had been placed on MEL (not supposed to be operated). The MEL placard stated 'left pack cooling exit doors failed full closed' and referred to manual which just says 'air conditioning packs.' we did not interpret this correctly because the words packs inoperative were not written in the MEL or the logbook. After landing and discussing the problem with maintenance it was clear the pack was not supposed to be used. The engineer did a good job of monitoring the pack temperature and there was no damage done by operating the pack. The problem we had was hot output air in the cabin in order to keep the pack from overheating. We elected to turn the left pack off during the climb out and that cooled the cabin off. We also complied with single pack altitude restrs. The main problem here was that nothing jumped out at us and said 'do not use the pack.' supplemental information from acn 490919: a 'different' MEL would have allowed us to operate the pack with certain restrs but the MEL number that maintenance used called for the pack to be inoperative/unusable. In the rush, crew failed to notice the discrepancy between the write-up and the MEL that maintenance used.
Original NASA ASRS Text
Title: B727 CREW OPERATES AN AIR-CONDITIONING PACK THAT IS DEFERRED INOP EVEN THOUGH IT IS A FAILURE OF THE COOLING DOORS THAT IS THE PROB.
Narrative: CREW OPERATED L AIR CONDITIONING PACK WHEN THE PACK HAD BEEN PLACED ON MEL (NOT SUPPOSED TO BE OPERATED). THE MEL PLACARD STATED 'L PACK COOLING EXIT DOORS FAILED FULL CLOSED' AND REFERRED TO MANUAL WHICH JUST SAYS 'AIR CONDITIONING PACKS.' WE DID NOT INTERPRET THIS CORRECTLY BECAUSE THE WORDS PACKS INOP WERE NOT WRITTEN IN THE MEL OR THE LOGBOOK. AFTER LNDG AND DISCUSSING THE PROB WITH MAINT IT WAS CLR THE PACK WAS NOT SUPPOSED TO BE USED. THE ENGINEER DID A GOOD JOB OF MONITORING THE PACK TEMP AND THERE WAS NO DAMAGE DONE BY OPERATING THE PACK. THE PROB WE HAD WAS HOT OUTPUT AIR IN THE CABIN IN ORDER TO KEEP THE PACK FROM OVERHEATING. WE ELECTED TO TURN THE L PACK OFF DURING THE CLBOUT AND THAT COOLED THE CABIN OFF. WE ALSO COMPLIED WITH SINGLE PACK ALT RESTRS. THE MAIN PROB HERE WAS THAT NOTHING JUMPED OUT AT US AND SAID 'DO NOT USE THE PACK.' SUPPLEMENTAL INFO FROM ACN 490919: A 'DIFFERENT' MEL WOULD HAVE ALLOWED US TO OPERATE THE PACK WITH CERTAIN RESTRS BUT THE MEL NUMBER THAT MAINT USED CALLED FOR THE PACK TO BE INOP/UNUSABLE. IN THE RUSH, CREW FAILED TO NOTICE THE DISCREPANCY BTWN THE WRITE-UP AND THE MEL THAT MAINT USED.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.